Improving Emergency Department Airway Preparedness in the Era of COVID-19: An Interprofessional, In Situ Simulation

Audience The target audience for this airway simulation includes all emergency department (ED) staff who are potential members of a COVID-19 intubation team, including emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. Introduction As of May 7, 2020 there were 1,219,066 diagnosed cases of COVID-19 in the U.S. and 73,297 deaths.1 A special report from the Centers for Disease Control and prevention on infections in healthcare personnel reported 9,282 cases between February 12th and April 9th.2 Sars-CoV-2 is a novel virus that requires a careful, coordinated approach to airway management given the high risk of aerosolization.3 It is essential to train ED staff (1) to appropriately care for patients with suspected COVID-19 disease and (2) to provide an organized, safe working environment for providers during high-risk, aerosolizing procedures such as intubation. In addition to providing a set of airway management guidelines, we aimed to educate the staff through participation in a simulation activity. Due to the multiple team members involved and the array of equipment needed, an in-person in situ strategy was implemented. The goals of the simulation were to optimize patient care and minimize viral exposure to those involved during intubation. Educational Objectives At the conclusion of the simulation session, learners will be able to: 1) Understand the need to notify team members of a planned COVID intubation including: physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2) Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. 3) Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4) Appropriately select oxygenation therapies and avoid high-risk aerosolizing procedures. 5) Manage high risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel ®. Educational Methods This is a high-fidelity, interprofessional, in-situ simulation used to train a team of providers that would normally participate in the management of a patient with suspected COVID-19 requiring endotracheal intubation. Participants might include emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. The patient is best represented by a high-fidelity mannequin such as Trauma HAL® (Miami, FL USA) https://www.gaumard.com/products/trauma/trauma-halr), with a monitor displaying vital signs and voice-response capabilities. The simulation includes an interprofessional debriefing session, during which an airway checklist, communication strategies, and best practices are reviewed. Research Methods Airway management guidelines were developed by an interdisciplinary team at our institution. We used these guidelines from Stanford Health Care and best practices from a literature review to create a checklist of recommended steps. Two assessors used the checklist to track team actions. Any missed items were discussed in the team debrief and participants were encouraged to ask questions. At the end of the session, to check for understanding, participants were provided with a brief anonymous online survey accessed by a QR code. These assessments allowed the simulation team to iteratively edit the case before future simulations. Results From 3/23/20–4/23/20, we held 12 in-situ simulations with 62 participants, including emergency medicine physicians, nurses, technicians, respiratory therapists, and pharmacists. Two individuals observed each simulation and compared team performance to the checklist of recommended steps. The actions that were not completed during the simulation served as teaching points during the simulation debrief. The debrief discussions helped to identify misconceptions regarding oxygenation strategies, difficulties in staff communication due to physical barriers, and various other quality or safety concerns. Participant reactions following the simulation and debriefs were overwhelmingly positive. Discussion This simulation was an effective, easy-to-implement method of interprofessional team training for a risk-inherent procedure in the ED. We learned that the deliberate simulation of each step of the COVID19-specific intubation procedure with all team members provided opportunities to identify safety challenges in communication, equipment, and approach. Each debrief stimulated an excellent discussion among team members, and allowed for interprofessional feedback, clarification of questions, and recommendations for areas of improvement. Our main take-away from the pilot of this novel simulation case is that new, high-risk procedures require a coordinated team effort to minimize risks to patients and staff, and that team training is feasible and effective using frequent in situ simulations. Topics Medical simulation, in-situ simulation, interprofessional, COVID-19, novel coronavirus, SARS-CoV-2, intubation, medical education, health professions education, team training, airway management.


Linked objectives and methods:
This format allows for execution of each of these steps among an interprofessional team. The in-situ interprofessional simulation format was selected because it allows participants to appreciate the interdependence between team members. In addition, it was important to hold the simulation in the ED setting where these intubations occur, in order to enhance realism and allow for identification of systems issues. The interprofessional nature and setting helped to accomplish the first two learning objectives, which involve recruitment of the entire team and establishing in-room and out-of-room personnel. Participants had departmental guidelines available to them during the simulation, which facilitated familiarization prior to using the guidelines for a real patient. These guidelines helped the teams in collecting the appropriate equipment, which accomplished objective three. In the debrief, any misunderstanding about the steps of the procedure were discussed. Special attention was given to the oxygenation strategies during the scenario, and if interventions such as bagging or non-invasive ventilation were used by the team, they were discussed as inappropriate methods of oxygenation in order to highlight objective four. Finally, to assess objective five, the scenario involved a complication such as hypotension or hypoxemia in order for the team to practice integrating rescue medications or placing rescue airway devices. After the scenario, the interprofessional team debrief discussion allowed for identification of systemic quality issues related to the five objectives that otherwise may have been encountered during actual patient care.
Recommended pre-reading for instructor: Note: these references were recommended at the time of submission, but this is subject to change with rapidly evolving information about the virus. One attending, one resident, two nurses, one pharmacist, one technician, and one respiratory therapist for a total of up to seven learners per case. If one of these participants cannot attend, a confederate may perform the actions of that healthcare professional.

Objectives:
After completion of the simulation, learner will be able to: 1. Understand the need to notify the team members of a planned COVID intubation including the physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2. Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. In-room personnel includes 1-2 physicians, a respiratory therapist, and one nurse. All other staff remain outside of the room. 3. Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4. Review oxygenation therapies for COVID patients and understand the need to avoid unnecessary aerosolizing procedures such as bagging. 5. Review management of high-risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel®.

Learner responsible content (optional):
Learners should be familiar with their own institutional guidelines for intubation of suspected COVID-19 patients. In addition, review of references listed above is optional based on learner role and interest.

Associated content (optional):
• Check for understanding survey example • COVID Airway Team Performance Checklist (note this checklist has 26 items instead of 28 due to the removal of two items that were institution-specific in an effort to make the checklist more generic)

Results and tips for successful implementation:
From 3/23/20-4/23/20, we held 12 in-situ simulations with 62 participants, including emergency medicine physicians, nurses, technicians, respiratory therapists, and pharmacists. Two individuals observed each simulation for completion of checklist items. The average performance on the checklist was 89% (range 75%-100%), or three items incorrect on a checklist of 28 items. The actions that were not completed during the simulation served as teaching points during the simulation debrief. Commonly missed items included obtaining a weight early on to facilitate the pharmacist's preparation of medications and attaching the bag valve mask to oxygen prior to rapid sequence intubation.
The simulations provided an opportunity to clarify misconceptions regarding recommended oxygenation strategies in COVID-19 patients, thereby minimizing potential aerosolization. The debriefs identified difficulties in staff communication through the relatively soundproof isolation room doors, resulting in increased use of available video conferencing between in-room and outside-room providers. Various technical challenges with the procedure were addressed such as appropriate use of viral filters, communicating medication dosing with outside-room pharmacists, use of outside-room interpreters, exchanging airway equipment for smaller patients, safely obtaining radiographs through the exam room glass doors, and optimally placing personnel and equipment in the room. Additionally, we were able to identify several quality and safety concerns that were subsequently addressed with the appropriate individuals. This is ideally implemented as an on-shift in situ simulation during lower volume hours in the ED. We found that 6am was the best time to run the scenario with the night shift team before signing out, and 8am was the best time to run the scenario with the day shift team. It was important that all team members were represented to ensure a successful simulation. If one could not make it due to a patient care obligation, the simulation instructors filled in as confederates. It was critical to provide a pre-brief to the team with introductions of each participant, orientation to the mannequin, and expectations for the scenario, including verbalizing (rather than donning) personal protective equipment. We found the simulation duration varied between 18-30 minutes, so it was important to respect participants' time by keeping the debrief to less than 10 minutes. We created a case-specific checklist to track critical steps that teams performed or didn't perform in order to address these steps during the debrief. A short objective-based survey was provided to inform authors of any modifications needed during future simulations. Finally, there was ample time for discussion about quality improvement or safety issues, and the simulation team escalated any recommendations to the appropriate leadership. This case involves a single patient who presents to the emergency department (ED) by EMS in respiratory distress. He starts in an isolation room with a bedside nurse who performs the initial assessment. The resident and attending are alerted to a new patient roomed in their zone and review the appropriate data in the electronic medical record (Epic Playground training environment). One of the physicians may opt to enter the room upon arrival. Initial orders are placed and communication occurs with the bedside nurse about initial plan of care. The patient has signs of decompensation (respiratory distress and altered mental status) and requires intubation. The physician must activate the entire interprofessional team, including the respiratory therapist, ED pharmacist, bedside nurse, a second nurse if available, and an ED technician. The team performs a huddle outside the room to organize team members and in-room and out-of-room equipment. Personal protective equipment (PPE) is donned (verbalized, in order to conserve PPE). The inroom team sets up for intubation, administers RSI medications, and performs intubation. Intubation is complicated by hypotension (or alternatively, instructors may choose to make the complication a failed intubation). After appropriate intervention of push-dose vasoactive medications, there is an improvement of blood pressure (or placement of I-gel®/LMA in event of failed intubation). Successful endotracheal tube placement is confirmed by through-theglass chest X-ray. Post-intubation sedation and analgesia must be verbalized, along with ventilator settings. An electrocardiogram (EKG) printed demonstrating sinus tachycardia (printed) (If desired, not essential) Background and brief information: A 2-minute pre-brief will be provided prior to the start of the simulation. An introduction to the mannequin, the monitor, and the purpose of the scenario will be reviewed. We will also discuss the need to verbalize personal protective equipment (PPE) in order to conserve supplies. The individuals recruited to participate will include the resident physician, the attending physician, two nurses, a respiratory therapist, an ED technician, and a pharmacist.

INSTRUCTOR MATERIALS
The setting is an emergency department. The patient will arrive by ambulance and will be roomed immediately. The EMS provider (confederate) will provide a brief report to the bedside nurse, who will perform initial assessment. The remainder of the team will be nearby and aware that the simulation is occurring, but not yet involved in the case. The triage note and vital signs will be pre-loaded into Epic Playground. The resident and attending physician will initiate the case in the charting area and review the patient's record in Epic Playground training environment or on word document or power point.

Initial presentation:
The patient presents by ambulance. He was brought in from a SNF where there have been multiple other residents that have tested positive for COVID-19. He has had a cough for one week and fever and shortness of breath for one day. This morning he was found to be altered and in respiratory distress. His vital signs were checked this morning and his room air oxygen saturation was 67%; therefore 911 was called.
How the scene unfolds: The patient arrives by EMS (confederate) and the bedside nurse receives handoff. The physicians will have access to the triage note in Epic Playground. One physician may opt to go into the room upon patient arrival. The other physician will communicate with video conferencing software, iPad, or phone, and will place initial orders. Upon assessment, the patient will be altered with a GCS (Glasgow Coma Scale) of 13 and in significant respiratory distress. The team may escalate to nasal cannula, followed by placement of a non-rebreather mask. They may opt to trial high-flow nasal cannula, but if they do, the patient will decompensate with worsening respiratory distress and become obtunded. The physician will verbalize the need to intubate the patient. The team will be recruited and perform a huddle outside of the room. The in-room team will enter and perform intubation. The team will encounter at least one complication of intubation such as hypotension, and they will be required to address this in the scenario (option to skip this step for an early learner). The case will end with obtaining a post-intubation chest x-ray, and ICU contact for disposition, if desired.
Critical actions: 1. Team recognized the need for intubation and notifies appropriate team members, including physician, nurses, respiratory therapist, pharmacist, and an ED technician. 2. In-room providers were limited to the physician (two if resident intubates), respiratory therapist, and nurse. 3. Learners proceeded to intubation in a decompensating patient without bagging or other unnecessary aerosolizing procedures. 4. Learners selected rapid sequence intubation medications such as etomidate OR ketamine for sedation and rocuronium for paralysis, and verbalized exact doses. 5. The endotracheal tube was connected directly to the ventilator. 6. Team anticipated and effectively treated post-intubation hypotension.  • History of present illness: 65-year-old male with history of hypertension, diabetes and recent right intramedullary nail placement for femoral fracture presents from an SNF with cough and fever and shortness of breath for one day. There have been multiple other residents that have tested positive for COVID-19 at the facility. This morning he was in respiratory distress and altered. His vital signs were checked this morning and his saturation was 67%; therefore 911 was called. He is complaining of shortness of breath, but denies chest pain, nausea, or vomiting.